Providing Promise

Specialized locomotor training helps patients enhance their mobility

For many people who have suffered a spinal cord injury, regaining independence and mobility used to be a pipe dream. Through the efforts of the Christopher and Dana Reeve Foundation, with the cooperation of the Centers for Disease Control and Prevention, that dream has become a reality for a subset of determined patients.

As of March 2014, 568 patients have either completed or are currently enrolled in treatment at the eight North American partner sites of the NeuroRecovery Network. Eighty of them are now able to walk in their homes and communities.

Locomotor training through the Neuro­Recovery Network follows a standardized three-step plan: bodyweight-supported treadmill training with manual assistance, over-ground walking training, and community reintegration. The program is open to patients who have sustained either a complete or incomplete cervical or thoracic spinal cord injury and have retained some muscle tone in their legs. They are referred by their physician.

Potential candidates must also be screened by an NRN physician and physical therapist to eliminate those with medical conditions counterintuitive to locomotor training.

Jeffrey Buehner (standing), Matt Bjelac (left), and Kendall Krieg (right) work with Ohio State University Wexner Medical Center NeuroRecovery Network patient Michael Neill on bodyweight-supported treadmill training with manual faciliation. The training is all about loading the patient's body weight and placing him into optimal alignment.

Joining the Network

Ohio State University Wexner Medical Center became part of the NeuroRecovery Network in 2007 when D. Michele Basso, PT, EdD, wrote a successful grant and was asked by the Reeve Foundation to join. The NRN is a strong example of translational research, where clinicians can study what they learn as they treat patients.

That component attracted Jeffrey Buehner, PT, MS, NRN co-clinical supervisor at the medical center. In addition to handling day-to-day operations, Buehner explained, "I get to be involved with the research aspects of it, which is one of the best parts of my role in the clinic."

The Institute for Rehabilitation and Research at Memorial Hermann in Houston first joined the NRN in 2005. At that time, they saw it was an opportunity for growth, and sent staff for training.

"It was really controversial when we started," said Marcie Kern, PT, MS, NRN clinical supervisor. There were different philosophies between the NeuroRecovery Network and Memorial Hermann regarding SCI patients. The NRN requires patients to wean off their spasticity medication, but Memorial Hermann had a heavy spasticity medication component and still does for its non-NRN spinal cord patients. However, the clinicians who attended that initial training were able to convince their colleagues of the benefits entering the NeuroRecovery Network. As Kern explained, "It's the largest clinical trial you can get into in rehab."

Each year, there are regional trainings for the NRN, where clinicians learn the latest scientific theories and receive hands-on practice. Representatives from each member facility meet annually, and clinical supervisors and directors participate in a monthly conference call.

As for spasticity medication, the NRN protocol helps with modulation and spasticity. Patients have reported being less "foggy" in their heads, and having a better connection with their body after ceasing their medication. A high percentage of them stay off their medications after the trial.

'Waking Up' the Nervous System

The NRN trains patients to move and walk the same way they did before their injury, in order to "wake up" the nervous system below the level of injury. The program starts with one hour of BWSTT with manual facilitation.

The training is all about loading the patient's body weight, and putting them in optimal alignment. It has the advantage of adjustability, through which the physical therapist can make it easier for the patient or challenge them. "I can read a patient's ability and give them encouragement," Kern said.

Buehner agreed. "The treadmill environment is a very permissive environment. We can control bodyweight support, speed of treadmill, and direction of treadmill." Therapists control all aspects in a fixed environment, providing cues to help patients fine-tune their nervous system. "In this environment, we are looking to retrain the neuromuscular system below the level of injury," he said.

Typically, there are four physical therapists and technicians involved - one to assist with each leg, one to assist with the hips, and one to run the computer, where the bodyweight support and treadmill speed are controlled.

The hips are the trickiest component. Patients must be able to control proper hip movement if they want to walk over ground without assistance.

Over-ground training is phase two of the locomotor training plan. The focus is usually on the patients' greatest functional limitations. This phase includes sitting, standing, walking and transfers.

"We stay away from assistive devices as much we can," noted Buehner. "However they did the task before injury is how we train them to do the task now. Task specificity and repetition are key." For instance, they encourage patients not to use their arms when transitioning from sit to stand.

"What did we challenge today, and how can we continue that in over-ground?" asked Kern. "It's not just tied to the treadmill, but the bigger picture." She urged her colleagues at other facilities to determine whether they can apply the same principles without the equipment.

Challenging patients to increase load and decrease compensation is a key component of spinal cord injury rehab. Kern suggested trying to make wheelchair-bound patients less dependent on slide boards for transfers, for example, or encouraging more load-bearing in the trunk, and not sitting passively while in the chair. Patients also spend time each day standing.

In Buehler's opinion, the third part of the protocol, community reintegration training, is the most pivotal. Patients are only at the facility a few hours at a time, and are home or out in the community for the rest of the day. Getting buy-in from the patients and painting a picture that rehab is a 24-hour process is important to the success of the NeuroRecovery Network. "They incorporate what they do each day at home," said Buehner. "It has to become part of their lives."

Promising Progress

This therapeutic protocol has returned valuable patient outcomes, as the clinical coordinators can attest. Kern calls one patient's progress "absolutely amazing." She was a middle-aged woman who came to Memorial Hermann three months post-injury, fully non-ambulatory. She made daily discoveries about what she could do. When her 60 sessions were up, she could walk.

Although that story is extreme, Kern said, "Everyone gets some sort of benefit." She admitted she was a bit skeptical when ASIA-A and ASIA-B patients were able to enter the network, but even some of them have shown improvement. Although he did not regain full mobility, one patient can now sit in his wheelchair, reach forward with both hands, and work in his garden, after previously having to hold on for stability.

Success stories are everywhere. At Ohio State University Wexner Medical Center, Buehner recalled a patient with an incomplete C5 injury who was power wheelchair dependent, and dependent for all transfers. When he left the program, he used a wheeled walker, was able to drive, and returned to college. A woman with a T6 incomplete injury has been in the NRN since November 2013. "She came to us wheelchair dependent. She's progressing every day," noted Buehner. Currently, she spends more time walking with the assistance of a wheeled walker than in her wheelchair, and is independent with her transfers.

The average number of visits in the NeuroRecovery Network program is 60. After every 20 sessions, patients are re-evaluated and treatment goals are developed for the next 20.

There is a fixed discharge algorithm. Buehner said, "The ideal is that when we're done with them, they're where they need to be and continue on with their lives, but that's not always the case."

When it comes time to leave the NRN, a panel meets to discuss the best way to get patients where they need to be in their recovery. Sometimes insurance companies will extend coverage and patients can go through additional cycles. When that's not the case, patients can be discharged to outpatient physical therapy. Others are encouraged to continue exercises on their own. "We teach them to advance themselves," said Kern.

Advancement is the name of the game with locomotor training. Physical therapists help patients move on the next phase in their rehab, and more importantly, their lives.

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